Family Planning in Asia and the Pacific - International Council on ...

each a source of family plann<strong>in</strong>g services.Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, monitor<strong>in</strong>g offamily plann<strong>in</strong>g programmes could not be carried outeffectively due to frequent b<strong>and</strong>hs (strikes) <strong>and</strong> threatsto personal safety dur<strong>in</strong>g <strong>the</strong> Maoist conflict (1996-2006). In addition, <strong>the</strong> b<strong>and</strong>hs also affected <strong>the</strong> transportof contraceptive commodities to health facilities <strong>and</strong>clients’ access to health facilities. This also affected <strong>the</strong>geographical distribution of health personnel. For example,health personnel from different ethnic backgrounds werereluctant to serve <strong>in</strong> conflict-affected regions.Difficult topographyNepal is divided <strong>in</strong>to three ecological zones: mounta<strong>in</strong>s,hills <strong>and</strong> pla<strong>in</strong>s (Terai). The impact of topography oncontraceptive use is shown <strong>in</strong> Table 8 below. About 45per cent of <strong>the</strong> population lives <strong>in</strong> <strong>the</strong> Terai <strong>and</strong> generallyhas better access to health-care services than people liv<strong>in</strong>g<strong>in</strong> o<strong>the</strong>r zones. <strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> reproductive healthservices are more limited <strong>in</strong> <strong>the</strong> hill <strong>and</strong> mounta<strong>in</strong> areasbecause few people want to work <strong>the</strong>re, <strong>the</strong> transportationis poor <strong>and</strong> supplies are limited. In addition, <strong>the</strong> high levelof out-migration of youth could contribute to <strong>the</strong> lowerCPR <strong>in</strong> those regions. Ow<strong>in</strong>g to those regions’ topography,it is also difficult to provide consistent tra<strong>in</strong><strong>in</strong>g. Tra<strong>in</strong>edhuman resources are concentrated <strong>in</strong> urban areas <strong>and</strong> someaccessible regions <strong>in</strong> <strong>the</strong> Terai (MoHP et al., 2006).Topography <strong>and</strong> physical <strong>in</strong>accessibility are associated withCPR <strong>in</strong> Nepal 2 . Among <strong>the</strong> 75 districts <strong>in</strong> Nepal, only 5of <strong>the</strong>m have a CPR of more than 60 per cent (2 are from<strong>the</strong> hills <strong>and</strong> 3 are from <strong>the</strong> Terai region). The majorityof central Terai districts fall under <strong>the</strong> middle level ofCPR classification while four districts from <strong>the</strong> hills alsofall under this classification. None of <strong>the</strong> mounta<strong>in</strong>ousdistricts have a CPR higher than 45 per cent. The eastern<strong>and</strong> central mounta<strong>in</strong> districts fall under <strong>the</strong> low CPR level,while almost all western <strong>and</strong> far-western mounta<strong>in</strong> districts(except Jumla <strong>and</strong> Mustang) fall under <strong>the</strong> very low CPRlevel. There are also a number of hill districts with very lowCPR, while <strong>the</strong>re is only one district <strong>in</strong> <strong>the</strong> Terai <strong>in</strong> thiscategory. Yet caution must be taken that some of <strong>the</strong> hillsdistricts with relatively good physical <strong>in</strong>frastructure, suchas Kaski <strong>and</strong> even Kathm<strong>and</strong>u, fall under <strong>the</strong> low CPRlevel, <strong>in</strong>dicat<strong>in</strong>g that physical access is not <strong>the</strong> only factordeterm<strong>in</strong><strong>in</strong>g CPR. In <strong>the</strong> Terai, where CPR is low or verylow, cultural <strong>and</strong> programmatic factors may be importantdeterm<strong>in</strong>ants (Table 8).In addition, data show that TFR is much higher <strong>in</strong> ruralareas, <strong>in</strong> mounta<strong>in</strong>, mid- <strong>and</strong> far-western developmentregions. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, CPR is much lower <strong>in</strong> <strong>the</strong>seareas <strong>and</strong> unmet need for family plann<strong>in</strong>g is substantiallyhigh <strong>in</strong> <strong>the</strong>se areas. Thus, <strong>the</strong>se places must be targetedby <strong>the</strong> programme <strong>in</strong> order to fur<strong>the</strong>r achieve fertilitydecl<strong>in</strong>e.Socio-cultural barriers tocontraceptive usePower relationsUnderly<strong>in</strong>g factors for low use of family plann<strong>in</strong>g <strong>in</strong> Nepalcould be associated with asymmetrical power relationsbetween husb<strong>and</strong>s <strong>and</strong> wives. For example, femalesterilization is more popular <strong>in</strong> <strong>the</strong> Terai where <strong>the</strong> statusof women is lower <strong>and</strong> <strong>the</strong>y have less decision-mak<strong>in</strong>gpower. Thus, female autonomy is an important factorfor expla<strong>in</strong><strong>in</strong>g unmet need <strong>and</strong> low utilization of familyplann<strong>in</strong>g services.Son preferenceLeone et al. (2003) exam<strong>in</strong>ed <strong>the</strong> impact of son preference<strong>in</strong> Nepal on contraceptive use <strong>and</strong> fertility decl<strong>in</strong>e,draw<strong>in</strong>g data from NFHS 1996. Their results <strong>in</strong>dicatedthat sex preference decreases contraceptive use by 24 percent <strong>and</strong> <strong>in</strong>creases TFR by more than 6 per cent. Thus,<strong>the</strong>y concluded that <strong>the</strong> level of sex preference <strong>in</strong> Nepalis substantial. Sex preference is an important barrier to<strong>in</strong>creas<strong>in</strong>g contraceptive use <strong>and</strong> fertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong>country, <strong>and</strong> its impact will be greater as desired family sizedecl<strong>in</strong>es. A UNFPA study carried out <strong>in</strong> four districts ofNepal <strong>in</strong> 2007 found that Nepalese women are pressuredto give birth to a son. Those women who have givenbirth to two or more daughters consecutively were underparticularly high pressure, often <strong>in</strong> <strong>the</strong> form of threats from<strong>the</strong>ir mo<strong>the</strong>rs-<strong>in</strong>-law <strong>and</strong> husb<strong>and</strong>s. Such women have nochoice but to become pregnant repeatedly until a son is born.Statistically, <strong>the</strong> practices of prenatal sex determ<strong>in</strong>ation<strong>and</strong> sex-selective abortion were found to be very low <strong>in</strong><strong>the</strong> study population: only 3 per cent (74 women) of <strong>the</strong>ever-pregnant women, women who had been pregnantirrespective of <strong>the</strong> outcome of <strong>the</strong> pregnancy; women whohad ever sought prenatal sex-determ<strong>in</strong>ation tests; <strong>and</strong> only14 per cent of <strong>the</strong> women who had ever had an <strong>in</strong>ducedabortion had done so after prenatal sex determ<strong>in</strong>ation. Thestudy subsequently po<strong>in</strong>ted to prenatal sex selection ascurrently be<strong>in</strong>g at a prelim<strong>in</strong>ary stage <strong>in</strong> Nepal, <strong>in</strong> contrastto Ch<strong>in</strong>a <strong>and</strong> India, where it is a widespread phenomenon(UNFPA, 2007).Disadvantaged social groupsCPR, TFR <strong>and</strong> unmet need for family plann<strong>in</strong>g widely varyacross <strong>the</strong> social groups <strong>in</strong> Nepal (see Table 9). This justifies<strong>the</strong> cont<strong>in</strong>ued need of <strong>the</strong> family plann<strong>in</strong>g programme forsome social groups to ensure <strong>the</strong>ir reproductive goals.Among <strong>the</strong> social groups, Muslims have <strong>the</strong> highest TFR(4.6), lowest CPR (19%) <strong>and</strong> highest unmet need for familyplann<strong>in</strong>g (37%). CPR among <strong>the</strong>m is 0.4 times lower than183